Chapter 51
Management of Patients With
Immunodeficiency
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Learning Objectives
• Compare the different types of primary
immunodeficiency disorders and their causes, clinical
manifestations, potential complications, and treatment
modalities.
• Describe the nursing management of the patient with an
immunodeficiency.
• Identify the essential teaching needs for a patient with
an immunodeficiency.
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Primary Immunodeficiencies
• Usually seen in infants and young children
• Manifestations: vary according to type, severe or
recurrent infections, failure to thrive or poor growth,
positive family history
• Potential complications: recurrent, severe, potentially
fatal infections; related blood dyscrasias or malignancies
• Treatment: varies by type, treatment of infection, pooled
plasma or immunoglobulin, GM-CSF or GCSF, thymus
graft, stem cell or bone marrow transplant
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Immunodeficiency Disorders
• Primary
– Genetic
– May effect phagocytic function, B cells and/or T cells,
or the complement system
• Secondary
– Acquired
– HIV/AIDS
– Related to underlying disorders, diseases, toxic
substances, or medications
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Nursing Management
• Monitor for signs and symtoms of infections
– Note symptoms of inflammatory response may be
blunted
• Monitor lab values
• Promote good nutrition
• Address anxiety, stress, and coping
• Strategies to reduce risk of infection
– Handwashing and strict aseptic technique
– Patient protection and hygiene measures: skin care,
promote normal bowel and bladder function,
pulmonary hygiene
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Patient Teaching
• Signs and symptoms of infection
• Medication teaching
• Prevention of infection
– Handwashing
– Avoid crowds and persons with infections
– Hygiene and cleaning
• Nutrition and diet
• Lifestyle modifications to reduce risk
• Follow-up care
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Question
Is the following statement True or False?
Severe combined immunodeficiency disease (SCID) is an
disorder involving a complete absence of humoral and
cellular immunity resulting from an X-linked or autosomal
genetic abnormality.
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Answer
True
Severe combined immunodeficiency disease (SCID) is an
disorder involving a complete absence of humoral and
cellular immunity resulting from an X-linked or autosomal
genetic abnormality.
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Chapter 52
Management of Patients With
HIV Infection and AIDS
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Learning Objectives
• Describe the modes of transmission of HIV infection and
prevention strategies.
• Describe the host/HIV interaction during primary infection.
• Explain the pathophysiology associated with the clinical
manifestations of HIV/AIDS.
• Describe the clinical management of patients with HIV/AIDS.
• Discuss the nursing interventions appropriate for patients with
HIV/AIDS.
• Use the nursing process as a framework for care of the patient
with HIV/AIDS.
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Transmission of HIV
• Transmitted by body fluids containing HIV or infected
CD4 lymphocytes
– Blood, seminal fluid, vaginal secretions, amniotic
fluid, and breast milk
– Most prenatal infections occur during delivery
• Casual contact does not cause transmission
• Breaks in skin or mucosa increase risk
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High-Risk Behaviors
• Sharing infected injection equipment
• Having sexual relations with infected individuals
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Question
Is the following statement True or False?
The major means of HIV transmission are unprotected sex
and the sharing of injection drug use equipment.
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Answer
True
The major means of HIV transmission are unprotected sex
and the sharing of injection drug use equipment.
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Prevention
• Standard precautions
• Safer sex practices and safer behaviors
– Abstain from sharing sexual fluids
– Reduce the number of sexual partners to one
– Always use latex condoms; if allergic to latex, use
non-latex condoms
• Do not share drug injection equipment
• Blood screening and treatment of blood products
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HIV Life Cycle
• Attachment
• Uncoating
• DNA synthesis
• Integration
• Transcription
• Translation
• Cleavage
• Budding
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Structure of HIV-1
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Life Cycle of HIV-1
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Stages of HIV Disease
• Primary infection
• HIV asymptomatic
• HIV symptomatic
• AIDS
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Primary Infection
• AKA acute HIV infection/acute HIV syndrome
• Part of CDC category A
• Symptoms: none to flu-like syndrome
• Window period: lack of HIV antibodies
• Period of rapid viral replication and dissemination
through the body
• Viral set point: balance between amount of HIV and the
immune response
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HIV Asymptomatic
• CDC category A
• More than 500 CD4+ T lymphpocytes/mm3
• Upon reaching the viral set point, chronic asymptomatic
state begins
• Body has sufficient immune response to defend against
pathogens
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HIV Symptomatic
• CDC category B
• 200–499 CD4+ lymphpocytes/mm3
• CD4 T cells gradually fall
• The patient develops symptoms or conditions related to
the HIV infection, which are not classified as category C
conditions
• Patients who are once treated for a category B condition
are considered category B
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AIDS
• CDC category C
• Less than 200 CD4+ lymphocytes/mm3
• As levels drop below 100 cell/mm3 the immune system is
significantly impaired
• Development of listed conditions
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Treatment
• Treatment and protocols are continually evolving
• Antiretroviral agents
– Nucleoside reverse transcriptase inhibitors (NRTIs)
– Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
– Protease inhibitors (PIs)
– Fusion inhibitors
– Use of combination therapy
• Management also focuses upon the treatment of specific
manifestations and conditions related to the disease
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Question
Is the following statement True or False?
A fungal infection present in almost all patients with
HIV/AIDS is Kaposi’s sarcoma.
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Answer
False
A fungal infection present in almost all patients with
HIV/AIDS is candidiasis, not Kaposi’s sarcoma.
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Clinical Manifestations of HIV/AIDS:
Respiratory
• Pneumocystic carini pneumonia (PCP):
– Most common infection
– Initial symptoms may be nonspecific and may include
nonproductive cough, fever chills, dyspnea, and
chest pain
– If untreated, progresses to pulmonary impairment
and respiratory failure
– Treatment: TMP-SMZ or pentamidine, prophylactic
TMP-SMZ
• Mycobacterium avium complex (MAC)
• Tuberculosis
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Clinical Manifestations of HIV/AIDS: GI
• Oral candidiasis
– May progress to esophagus and stomach
– Treatment with Mycelex troches or nystatin,
ketoconazole
• Diarrhea related to HIV infection or enteric pathogens
– Octretide acetate for severe chronic diarrhea
• Wasting syndrome
– 10% weight loss and chronic diarrhea or chronic
weakness and fever with absence of other cause
– Protein energy malnutrition
– Anorexia, diarrhea, GI malabsorption, and lack of
nutrition may contribute
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Clinical Manifestations of HIV/AIDS:
Oncologic
• Kaposi's sarcoma
– Cutaneous lesions, but may involve multiple organ
systems
– Lesions cause discomfort, disfigurement, ulceration,
and potential for infection
• B-cell lymphomas
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Lesions of Kaposi’s Sarcoma
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Manifestations of HIV/AIDS: Neurologic
• HIV encephalopathy
– Progressive cognitive, behavioral, and motor decline
– Probably directly related to the HIV infection
• Cryptococcus neoformans
• Other neurologic disorders
• Depression
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Nursing Process: The Care of the Patient
with HIV/AIDS—Assessment
• Assess physical and psychosocial status
• Identify potential risk factors: IV drug abuse, risky sexual
practices
• Immune system function
• Nutritional status
• Skin integrity
• Respiratory status neurologic status
• Fluid and electrolyte balance
• Knowledge level
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Nursing Process: The Care of the Patient
with HIV/AIDS- Diagnosis
• Impaired skin integrity
• Diarrhea
• Risk for infection
• Activity intolerance
• Disturbed thought processes
• Ineffective airway clearance
• Pain
• Imbalanced nutrition
• Social isolation
• Anticipatory grieving
• Deficient knowledge
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Collaborative Problems/Potential
Complications
• Opportunistic infections
• Impaired breathing or respiratory failure
• Wasting syndrome
• Fluid and electrolyte imbalance
• Adverse reaction to medication
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Nursing Process: The Care of the Patient
with HIV/AIDS—Planning
• Goals may include:
–
Achievement and maintenance of skin integrity
–
Resumption of usual bowel patterns
–
Absence of infection
–
Improved activity tolerance
–
Improved thought processes
–
Improved airway clearance
–
Increased comfort, improved nutritional status
–
Increased socialization
–
Expression of grief
–
Increased knowledge regarding disease prevention and self-care
–
Absence of complications
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Skin Integrity
• Frequent routine assessment of skin and mucosa
• Encourage patient to maintain balance between rest and
activity
• Reposition at least every 2 hours and as needed
• Pressure reduction devices
• Instruct patient to avoid scratching
• Use gentle, nondrying soaps or cleansers
• Avoid adhesive tape
• Perianal skin care
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Promoting Usual Bowel Pattern
• Assess bowel pattern and factors that may exacerbate
diarrhea
• Avoid foods that act as bowel irritants, such as raw fruits
and vegetables, carbonated beverages, spicy foods, and
foods of extreme temperatures
• Small, frequent meals
• Administer medications as prescribed
• Assess and promote self-care strategies to control
diarrhea
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Activity Intolerance
• Maintain balance between activity and rest
• Instruction regarding energy conservation techniques
• Relaxation measures
• Collaboration with other members of the health care
team
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Maintaining Thought Processes
• Assess mental and neurologic status
• Use clear, simple language if mental status is altered
• Establish and maintain a daily routine
• Orientation techniques
• Ensure patient safety and protect from injury
• Strategies to maintain and improve functional ability
• Instruct and involve family in communication and care
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Nutrition
• Monitor weight, I&O, dietary intake, and factors that
interfere with nutrition
• Dietary consult
• Control of nausea with antiemetics
• Oral hygiene
• Treatment of oral discomfort
• Dietary supplements
• May require enteral feedings or parenteral nutrition
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Decreasing Isolation
• Promote an atmosphere of acceptance and
understanding
• Assess social interactions and monitor behaviors
• Allow patient to express feelings
• Address psychosocial issues
• Provide information related to the spread of infection
• Educate ancillary personnel, family, and partners
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Other Interventions
• Improving airway clearance
– Position in semi-Fowler's or high Fowler’s
– Pulmonary therapy; coughing and deep breathing,
postural drainage, percussion, and vibration
– Ensure adequate rest
• Pain
– Medications as prescribed
– Skin and perianal care
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Question
What antiretroviral medication when taken with a highfat/high-caloric meal increases peak plasma
concentrations of capsules?
A. Delavirdine (Rescriptor)
B. Efavirenz (Sustiva)
C. Nevirapine (Viramune)
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Answer
B
The antiretroviral medication that when taken with a highfat/high-caloric meal increases peak plasma
concentrations of capsules is efavirenz (Sustiva).
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Chapter 54
Management of Patients With
Autoimmune Disorders
•Rheumatoid Arthritis
•Lupus
•Scleroderma
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Learning Objectives
• Explain the pathophysiology of selected autoimmune disorders
(diffuse connective tissue disease).
• Describe the assessment and diagnostic findings that may be seen in
patients with a suspected diagnosis of diffuse connective tissue
disease.
• Discuss appropriate nursing interventions based on nursing diagnoses
and collaborative problems that commonly occur with diffuse
connective tissue disease.
• Describe the systemic effects of a diffuse connective tissue disease.
• Identify modifications in interventions to accommodate changes in
patients’ functional ability that may occur with disease progression.
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Question
Is the following statement True or False?
Diarthrodial is bleeding into a joint.
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Answer
False
Diarthrodial is a joint with two freely movable parts.
Hemarthrosis is bleeding into a joint.
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Diffuse Connective Tissue Diseases
• A group of chronic disorders characterized by diffuse
inflammation and degeneration in the connective tissue
• Cause is unknown but thought to have an immunologic
basis
• Characterized by a clinical course of exacerbations and
remissions
• Includes SLE, scleroderma, polymyositis, and
polymyalgia rheumatica
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Rheumatoid Arthritis
• More than 100 different disorders
• Affect primary the joints, but also muscles, bone,
ligament, tendons, cartilage
• Classification:
– Monoarticular or polyarticular
– Inflammatory or noninflammatory
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Characteristic Degenerative Changes—
“Degradation”
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Clinical Manifestations
• Pain
• Joint swelling
• Limited movement
• Stiffness
• Weakness
• Fatigue
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Pathophysiology and Associated Physical
Signs of Rheumatoid Arthritis
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Patient Assessment and Diagnostic
Findings
• Health history: include onset of and evolution of
symptoms, family history, past health history, and
contributing factors
• Functional assessment
• Arthrocentesis
• X-rays, bone scans, CTs, and MRIs
• Tissue biopsy
• Blood studies
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Nursing Interventions
• Understanding of the underlying disease process guide;
the nurse’s critical thinking to provide interventions
• The extent of the disease process, and whether it is
localized or more systemic, will also affect nursing
activities
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Nursing Process: The Care of the Patient
with a Rheumatoid Arthritis—Assessment
• Health history and physical assessment focus on current
and past symptoms, and also include the patient's
psychological and mental status, social support systems,
ability to participate in daily activities, comply with
treatment regimen, and manage self-care
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Nursing Process: The Care of the Patient
with a Rheumatoid Arthritis—Diagnoses
• Acute and chronic pain
• Fatigue
• Disturbed sleep pattern
• Impaired physical mobility
• Self-care deficits
• Disturbed body image
• Ineffective coping
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Collaborative Problems/Potential
Complications
• Adverse effects of medications
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Nursing Process: The Care of the Patient
with a Rheumatoid Arthritis—Planning
• Major goals may include:
– Relief of pain and discomfort
– Relief of fatigue
– Promotion of restorative sleep
– Increased mobility
– Maintenance of self-care
– Improved body image
– Effective coping
– Absence of complications
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Question
With which of these diagnoses should the nurse encourage
the patient to restrict consumption of foods high in
purine?
A. Fibromyalgia
B. Gout
C. Osteoarthritis
D. Rheumatoid arthritis
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Answer
B
The nurse encourage the patient to restrict consumption of
foods high in purine for gout.
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Systemic Lupus Erythematosus (SLE)
• AKA Lupus
• Incurable autoimmune disease
• Cause is unknown
• Affects 20-50:100,000 with an annual incidence of
1.6-7.6:100,000
• Onset between the ages of 15 and 45
• Women affected 8 times more often than men
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Risk Factors
• Exposure to certain viruses (e.g., Epstein-Barr virus)
• Environmental factors (e.g., sunlight, thermal burns)
• Genetic factors
• Hormonal factors
• Certain drugs have been shown to induce SLE
–
Hydralazine
–
Procainamide
–
Isoniazid
–
Chlorpromazine
–
Some anti-seizure medications
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Signs and Symptoms/Clinical Presentation
• Musculoskeletal symptoms:
– Arthralgia
– Arthritis
– Joint swelling and tenderness
– Pain on movement
• Cutaneous symptoms:
– Malar (butterfly) rash (present in 50% of SLE)
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Signs and Symptoms/Clinical Presentation
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Teaching Patients Self-Care
• Explain the disease and principles of disease
management
• Medication teaching
• Monitoring
• Sources of information
• Pain management
• Joint protection
• Self-care with assistive devices
• Exercise and relaxation
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